Ten Questions for Your Managed Care Plan

Before enrolling in a new managed care health plan, you need to be sure that you’re comfortable with the services that it will provide. Sometimes your employer will pick a plan for you, in which case you should be aware of its rules. Sometimes you can choose a plan yourself, but not without answers to some pointed questions which you should pose. Here are ten questions (and some appropriate answers) to help you choose the right plan.

Which doctors can I choose? A managed care network can’t be any better than the doctors and other service providers that it uses. Check to see if you recognize any of the providers’ names on the network list. You’re generally allowed to pick whichever primary-care doctor that you want, and to change to another if you’re not satisfied. Keep in mind, however, that a long list of doctors does not necessarily equate to a better healthcare network. Plans with high-quality reputations are often those with a central clinic and a closely-knit group of salaried doctors working together for their patients’ best treatment course.

Will the doctor treat me by phone? Will the doctor make you come in and wait for every minor illness, or can it be done over the phone for your convenience?

Does my primary doctor see patients from several care plans? If not, you may have to switch doctors if you change jobs. Different employers offer different plans. A change of jobs may require everyone in your family to start new medical relationships from scratch.

How easy, or difficult, is it to see a specialist? Generally, you must see your primary-care provider first so that he or she can assess the problem. If the doctor feels that a specialist is needed, a referral will then be given. Some doctors, however, will refer you over the phone, which is a substantial time-saver. A few HMOs will even let you see a specialist in the network without prior permission.

To what extent does the managed care plan control the drugs that my doctor can prescribe? HMOs and other managed care providers have formularies, which are lists of drugs its doctors are allowed to prescribe. Some lists are broad; others are quite limited. If you’re on a maintenance drug, for example, ask if it’s on their list. If it’s not, you need to know what the health plan is going to do about it.

Which hospitals are on the network list and do I have a choice of which I can use? Plans will usually list the best hospitals in the area, although they won’t necessarily let you go there all the time. The best hospitals may be reserved for the most serious illnesses, and you may find yourself in a less-costly place.

How convenient are the hospitals, doctors, and other service providers? You probably won’t want to go all the way across town when there are perfectly good services nearby.

How does the health plan handle preexisting conditions? Inquire if you and your family are immediately covered for illnesses that you may have recently had. There may or may not be a waiting period. People with chronic illnesses or disabilities should find out who the specialists are and how their illnesses will be handled by the plan.

What is the managed care plan’s policy on very expensive treatments such as organ transplants? They’ll probably tell you that it’s covered if it’s appropriate. And, of course, they will decide what’s appropriate at that time. Most plans won’t pay for treatments deemed to be “experimental”. This one may be difficult to get a definitive answer for; a doctor you trust might be able to give you some insight into how the plan will handle those circumstances.

What does the plan pay for mental illness and substance abuse? All health plans have sliced coverage in these areas, but mental health professionals have stated that HMOs have gotten especially tight. Patients with serious problems may only be given a handful of covered visits to a psychologist or psychiatrist. For a drug or alcohol problem, coverage may be pared down to as little as a week in a treatment program.

After a representative has answered all of these questions for you, make sure that they can provide the answers that they’ve given to you in writing. Remember, it’s only binding if it’s in black and white.